Bulimia nervosa

Symptoms Of Bulimia Nervosa

The typical symptoms of bulimia nervosa include:

Psychological and behavioral symptoms

• Being obsessive about food and weight

• Fear of gaining weight

• Eating large amount of food at once

• Loss of control during eating 

• Trying to lose weight by vomiting, exercising, dietary supplements, herbal products, or fasting after overeating

• Restricting calories between binge eating

• Self induced vomiting

• Peculiar eating habits or rituals

• Inappropriate use of laxatives or diuretics

• Irregular or absence of menstruation

• Anxiety

• Depression

• Low self-esteem

• Feelings of helplessness

• Intense unhappiness with self body shape and size

Physical symptoms

• Sore throat 

• Tiredness 

• Dental problems due to erosion of enamel from vomiting

• Swollen cheeks or jaw line

• Constipation

• Acid reflux

• Dehydration

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Causes Of Bulimia Nervosa

The exact cause of bulimia nervosa is not known. However, carious causes that are thought to trigger bulimia are discussed below:

Biological causes

Genetics

Genetics plays a very important role in developing eating disorders like bulimia nervosa.One bulimia susceptibility gene is linked to the short arm of chromosome 10. Another gene for bulimia is thought to be on chromosome 14.

Studies supporting this theory suggest that twin siblings have a 50% chance of having an eating disorder if the other twin has the disease. 

Neurobiology

Serotonin is a neurotransmitter that affects appetite and mood. Low levels of serotonin in some individuals can trigger eating disorders such as bulimia. These altered serotonin levels can lead to disturbed mood and binge eating. 

Psychological factor

The idea of having a perfect body also predisposes the person to develop bulimia nervosa. 

Socio-cultural factors

The cultural preferences for being lean due to exposure to social media or other factors that portray a slim body as an ideal symbol can also cause bulimia nervosa.

Types Of Bulimia Nervosa

According to the behavior, bulimia nervosa can be classified into two major types: 

• Purging type: In this, patients often use self induced vomiting as a technique to avoid weight gain after binge eating. Other techniques such as excessive use of laxatives and diuretics can also be used in order to prevent weight gain. 

• Non-purging type: This type is characterized by using other unappropriate means to avoid weight gain such as excessive exercise or fasting.

Risk Factors For Bulimia Nervosa

Age

The chances of bulimia nervosa is high in teenage years due to pressure of having a certain body type. 

Gender

This eating disorder often affects females as compared to males. Teen girls between 15 to 19 years of age are at higher risk of developing this disorder.

Family history

People with bulimia are more likely to come from families with a history of eating disorders, physical illness, and other mental health problems. Other illnesses, such as substance abuse, anxiety disorders, and mood disorders are common in people with bulimia.

Early menarche

Early start of menstruation (periods)or menarche can trigger bulimia nervosa due to sexual development which increases the need of attention. It also increases the deposition of adipose tissue in the body which can lead to dissatisfaction and trigger bulimia nervosa. 

Obesity

An obese person usually experiences pressure from family and peers to be thin which can trigger symptoms of bulimia nervosa. The increased body weight also triggers other risk factors of bulimia. 

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Dieting

The excessive calorie restriction for a long period of time can cause negative effects which can lead to binge eating and purging behavior. 

Note: Bulimia is very commonly seen in models and actors associated with the fashion or entertainment industry due to the obsession of having a perfect body. Studies suggest that about 40% of models engage in some sorts of eating disorders. 25% of models are reported to use self induced vomiting as a method to avoid weight gain. 

Diagnosis Of Bulimia Nervosa

DSM-5 guidelines

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the following diagnostic criteria for diagnosing bulimia nervosa. 

• Recurrent episodes of binge eating which is characterized by both of the following:  

  • Eating, in a discrete period of time (e.g., within a two hour period)

  • Lack of control over eating during the episode 

• Inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.

• Both of the above episodes occur at least once a week for three months.

• Self-evaluation depends upon body shape and weight.

• Binging or purging does not occur exclusively during episodes of behavior that would be common in those with anorexia nervosa.

There is no perfect test to diagnose bulimia nervosa. However, several tests are performed to check the effect of the disease on the overall health of the body.  

Physical exam

It includes assessment of the height, weight and the vital functions of the body such as heart rate, blood pressure, and temperature. Skin and nails are also examined in this condition. 

Lab tests

Lab tests do not confirm bulimia, however these tests are useful to determine any underline health illness. Some of the common lab tests include: 

• Complete blood count (CBC)

• Serum electrolyte test

• Thyroid test

• Liver function test

• Kidney function test

• Urinalysis

Psychological evaluation

This involves assessment of thoughts, feelings, and eating habits by a therapist or mental health provider. It may also involve filling a psychological self-assessment questionnaire.

Imaging studies

• X-rays: These are done to measure bone density and for assessing any stress fractures.

• Electrocardiogram (ECG): Self-induced vomiting in bulimia can cause hypokalemia (low level of potassium in blood) which can cause heart problems such as arrhythmias(irregular heartbeat). In such cases, ECG is done to diagnose the activity and function of the heart.

Specialist To Visit

Most people with bulimia think that they are normal and don’t accept that they are behaving abnormally. In such cases, following questions may help in diagnosing the condition. 

• Do you have repeated episodes of binge eating?

• Do you feel a lack of control over your eating during an episode?

• Do you engage in inappropriate purging behaviors?

• Have you experienced binge eating at least once a week for three months?

• Does your body weight or shape have a strong influence on your self-image?

Specialists that can help manage this condition include:

• Primary care physician

• Nutritionist

• Psychiatrist

• Gastroenterologist

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Prevention Of Bulimia Nervosa

There is no sure way to prevent bulimia nervosa because it is affected by several factors. However, following factors may help in reducing the risk of bulimia. 

• Adhering to lifestyle guidelines such as eating on time, eating a balanced diet, and exercising regularly. Sound and adequate sleep also plays a pivotal role in maintaining overall health.

• Developing a healthy attitude towards eating 

• Having a positive attitude towards body size and shape

• Education and awareness about bulimia nervosa

• Early treatment in case of any suspicion 

• Balancing work, social life, adequate rest, and exercise

• Maintaining a sound mental health

Treatment Of Bulimia Nervosa

The primary goal of therapy is to inhibit the two key symptoms of bulimia nervosa which are binge eating and purging. 

Pharmacotherapy

Anti- depression medications

These medications have shown to ease symptoms of bulimia nervosa which includes reducing the frequency of binge eating and vomiting episodes. Some egs include:

• Fluoxetine

• Citalopram

• Sertraline

• Trazodone

Anti-epileptic medications

These medications, such as topiramate, have shown a reduction in binge episodes. However, the side effects especially weight loss and cognitive problems should be carefully monitored while using this medication. 

Treatment of associated symptoms

Treatment of dehydration

Bulimia nervosa can lead to dehydration, for which advised medical intervention such as saline administration is indicated to compensate for the lost fluid. 

Treatment of constipation

Constipation is very common in bulimia nervosa. The treatment includes hydration, exercise and use of dietary fiber. In severe cases, low doses of polyethylene glycol and lactulose are used. 

Psychotherapy

Psychotherapy  helps the patient understand the issue in a better way and how to cope with it. The various types include: 

• Family-based therapy (FBT): Also called the Maudsley method, it engages parents/family in the process of restoring the patient to a healthy weight at home. 

• Cognitive behavior therapy (CBT): This therapy aims to improve mental health, and the primary focus is on addressing the distorted views on self body image.

• Dialectical behavior therapy (DBT): This therapy aims at recognizing the triggers and methods to manage the factors causing bulimia nervosa. DBT also helps patients in managing their mental health balance.

• Acceptance and commitment therapy: This therapy aims at developing self-motivation rather than changing your thoughts and feelings.

• Interpersonal therapy (IPT): This therapy helps patients to recognize and solve problems in their relationships. Improving relationships and mental health has been found to reduce eating disorder symptoms.

• Nutrition counseling: A counseling with a nutritionist can help you understand the importance of diet and restoring normal eating patterns.

Home-care For Bulimia Nervosa

Nutritional planning

The effective management of bulimia nervosa requires conscious eating through understanding the calorie intake and dietary needs of the body. Keep a record of what you are eating. A well balanced nutritional planning helps in overcoming the impulsive binge eating and purging. 

It is utmost important to make the right and informed food choices and develop sound eating.
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Yoga

The patients of bulimia nervosa have a lack of physical and mental control over their actions and thoughts of self-image respectively. Yoga is an excellent tool to relieve mental stress and in controlling behavioral symptoms. 

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Meditation

It aids in calming the mind and focusing on inner self. It has shown to improve the thought of self image and impulsive behavior such as binge eating.

Emotional self care

Low self-esteem is one of the major risk factors of bulimia nervosa. Self care includes constantly reminding yourself that you are a good & beautiful person, indulging in activities that you love, thinking about the moments of your success. This can actually help in the treatment of mood swings and depression.

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Complications Of Bulimia Nervosa

Most of the complications associated with bulimia nervosa are linked to the method used by the patient to eliminate foods from the body. Excessive vomiting and overuse of laxatives can also severely affect the digestive system. Various complications affecting the different body parts are discussed below:

Skin, hair and nails

Most of these complications start to appear when body mass index (BMI) drops below 16.  The complications include:

• Hair loss

• Dry skin

• Rapid growth of excessive hair especially on face)

• Swelling of the lips

• Orange discoloration of the skin due to excess carotene in the sweat

• Fragile nails

People of bulimia can develop Russell’s sign due to mechanically inserting the fingers into the mouth to induce vomiting. This sign refers to the abrasions on the back of the hand developed due to repetitive exposure of the hands into the mouth. 

Eyes and nose

The repetitive act of self-induced vomiting can cause red patches inside the white (conjunctiva) of the eye. Patients may also experience repeated episodes of nose bleeds due to purging.

Dental

The act of self induced vomiting exposes the oral cavity to gastric acid which can lead to several dental complications. Dental erosions are usually noticed after 6 months of regular onset of self induced vomiting. 

Binging on high carbohydrate content food and carbonated beverages can also lead to dental caries. The other dental complications that can develop over a period of time include:

• Increased tooth sensitivity

• Xerostomia (dry mouth)

• Gingivitis (inflammation of the gums)

• Gum irritation

• Gum bleeding

• Sialadenosis (salivary gland hypertrophy)

Throat

The repeated exposure of acidic contents to the vocal cords and surrounding areas can lead to: 

• Hoarseness in the voice

• Difficulty in swallowing

• Chronic cough

• Burning sensation in the throat

• Repeated sore throat

Gastrointestinal

Repeated vomiting can lead to several gastrointestinal complications that include:

• Esophagitis

• Esophageal erosions

• Esophageal ulcers

• Barrett’s esophagus (change in the mucosal lining of the esophagus)

• Gastrointestinal bleeding

Boerhaave’s syndrome (esophageal rupture) is a rare complication of bulimia nervosa. The syndrome is characterized by chest pain, shortness of breath. Painful yawning can also be seen in patients who have tachycardia (increased heart rate). 

Cardiac 

Dehydration due to vomiting can cause various cardiac complications. The excessive loss of electrolytes in vomiting can lead to hypokalemia – which is low levels of potassium which also negatively affects the heart. Some of the cardiac complications include: 

• Sinus tachycardia (electrical signals from the heart’s sinoatrial (SA) node make the heart to beat faster than normal)

• Low blood pressure

• Orthostasis (low blood pressure while standing)

The use of ipecac as an inducer for vomiting can also lead to several life threatening complications which include:

• Ventricular arrhythmias (irregular heartbeats which can lead to syncope and palpitations)

• Congestive heart failure

• Cardiac death

Lungs

In patients who purge via self vomiting, following complications may develop:

• Aspiration of regurgitated food (inhalation of gastric content into the airway)

• Pneumomediastinum (presence of air in the space in the chest between the two lungs)

Alternative Therapies For Bulimia Nervosa

Home remedies

Aloe vera: The binge eating and self induced vomiting in bulimia nervosa deprives the body from getting appropriate nutrition. It also causes bloating which makes the patient even more concerned about their body shape. Aloe vera soothes the stomach and also helps in reducing bloating.

Probiotics: Bulimia nervosa causes loss of beneficial bacteria that the body needs to maintain the good health of the gut. Probiotics heals the digestive system and also helps in the cultivation of good bacteria. It also increases the nutrient intake efficiency of the body.

Ginseng: It stimulates the appetite and also boosts mood. It has also shown to relieve anxiety and depression that is closely associated with bulimia nervosa.

Orange (santra): It is an excellent source of Vitamin C that helps in fighting any infection due to low immunity. They also stimulate appetite and help in reducing the desire to binge eat. 

Spinach (palak): It is a good source of folic acid that has shown to reduce depression. It also helps in rebuilding the health of the digestive system. 

Salmon: This fish is high in omega-3 fatty acid that helps in reducing anxiety and stabilizing mood. It also helps in balancing the metabolism of the body. 

Living With Bulimia Nervosa

Bulimia nervosa is a mental disorder and it affects one’s body, mind and soul. Living with bulimia nervosa can be challenging as the person always lives in dissatisfaction with their body image. Along with pharmacotherapy and conscious eating, following tips will also help the patients in speedy recovery. 

• Focus on your therapy.

• Take medications as directed.

• Eat when hungry, and stop when full.

• Appreciate your body.

• Say “no” to diets.

• Go for nutritional counseling to learn about healthy eating. 

• Try yoga and meditation.

• Be open and honest about your recovery.

• Be aware of the risk of relapse.

• Do things that make you happy.

• Engage yourself in some activities such as gardening, painting etc when the desire to binge is too high. 

• Join support groups.

• Build a good support system with your parents, partner or friends. 

• Get enough sleep.